21 st May 2012 Class 4 aturma4@gmail.com

2
Introduction
 “Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations.
Some versions include direct linkages to online consumer health information that is
relevant to the health conditions and treatments related to a specific patient”
PubMed - MeSH, 2010
 “Electronically stored and transmitted medical record that contains patient demographics, medical history, lab tests, X-rays, scans, prescription lists, and any
other relevant information” Wulsin, L. and Dougherty, A., 2008
Wulsin, L. and Dougherty, A., Health information technology - Electronic health records: a primer, California State Library, 2008 (http://www.library.ca.gov/crb/08/08-013.pdf) http://www.ncbi.nlm.nih.gov/mesh/68057286

3
Introduction
“a method of comparing the cost of a program with its expected benefits in dollars (or other currency); the benefit-to-cost ratio is a measure of total return expected per unit of money spent.
This analysis generally excludes consideration of factors that are not measured ultimately in economic
terms. Cost effectiveness compares alternative ways to achieve a specific set of results.”
(PubMed – MeSH, 1976)

4
Introduction
It is generally agreed that EHRs hold great promise for improving healthcare quality and efficiency
But healthcare is decades behind other industries dealing with Information Technology adoption
There is an urgent need for hospitals to adopt general EHR systems.
However, the efforts of government and other EHR advocates have not sufficiently accelerated the diffusion trajectory.
Lori T. Peterson et al., Assessing Differences Between Physicians’ Realized and Anticipated Gains from Electronic Health Record Adoption, 2009

5
Introduction
Investment budget Cost Savings Increased revenue
- Activities
- Personnel
- Executive management
- Human resource and finance
- Building
- Supplies
- Electronic health record
- Other operating expenses
 Eliminating costs of a storing paper records
 Downsizing personnel
Dukyong Yoona et al., Adoption of electronic health records in Korean tertiary teaching and general hospitals, 2012,
International Journal of Medical Informatics 81 (2012) 196 – 203
 Government incentives for use health IT
 Pay-for-performance incentives
IT – information technology

Discussion
6
Barriers
The amount of capital needed to purchase and implement the system
Uncertainty about return on the investment
Concerns about the ongoing cost of maintenance
Finding an EHR system that meets the organization’s needs
Resistance to implementation from physicians
Lack of adequate IT staff
Concerns about lack of future support for upgrading and maintaining the system
Concerns about “hacking”
Lack of interoperable IT systems in the marketplace
Concerns about inappropriate disclosure of patient information
Lack of capacity to select, contract for, and implement an EHR system
Hospitals with EHR Hospitals without EHR
53.8%
33.0%
27.3%
34.4%
22.3%
29.1%
16.7%
12.7%
13.4%
9.2%
11.1%
76.3%
40.0%
36.8%
35.2%
30.5%
27.0%
23.3%
19.2%
18.0%
10.9%
2.9%

Discussion
7
Facilitators Hospitals with EHR Hospitals without EHR
Additional reimbursement for the use of EHRs 68.1%
Incentives for the purchase and implementation of an
HER system (e.g., tax credits, low-interest loans, grants)
Technical assistance for implementation and process change
Objective evaluations of EHR capabilities and implementation experiences (“consumer reports” on
EHRs)
Published lists of certified EHR systems to assure the presence of necessary capabilities and functions
Changes in the law to protect physicians from personal liability for “hacking” or for privacy and security breaches
61.4%
57.0%
45.4%
40.6%
37.1%
Dukyong Yoona et al., Adoption of electronic health records in Korean tertiary teaching and general hospitals, 2012,
International Journal of Medical Informatics 81 (2012) 196 – 203
62.9%
58.7%
31.1%
34.1%
36.7%
32.4%

8
Research
Questions


http://aep.ist.utl.pt/divulgacao/publicacoes/

Aim
9
 To review the published literature regarding the financial costs and benefits of regional or national Electronic Health Records.
With this, we intend to …
 Find out which records characteristics are associated to a bigger investment return.
 Measure the differences relating to the return of investment between all regions.

10
Methods
A systematic review is a method of identifying, appraising, and synthesising research evidence. The aim is to evaluate and interpret all available research that is relevant to a particular review question . In a systematic review, the scope (for example, the review question and any subquestions and/or sub-group analyses) is defined in advance, and the methods to be used at each step are specified. The steps include: a comprehensive search to find all relevant studies; the use of criteria to include or exclude studies; and the application of established standards to appraise study quality.
Lucie Rychetnik, Penelope Hawe, Elizabeth Waters, Alexandra Barratt, Michael Frommer. A glossary for evidence based
public health. J Epidemiol Community Health2004;58:538-545 doi:10.1136/jech.2003.011585. (17/12/2011)

Methods
11
 Make an inventory of synonyms of the key terms of the research
KEY TERMS
EHR
Economics
SYNONYMOUS
Electronic Health Record
Electronic Medical Record
Electronic Patient Record
Personal Health Record
Personal Medical Record
Computer Patient Record
Computer Health Record
Computer Medical Record
Digital Health Record
Digital Medical Record
Digital Patient Record
Fees
Funding
Financing
Cost

12
Methods
KEY TERMS
Cost-benefit analysis
National
Regional
SYNONYMOUS
Cost-Benefit Analyses
Cost Benefit Analysis
Cost Effectiveness
Cost-Benefit Data
Cost Benefit
Benefits and Costs
Costs and Benefits
National Health Programs
National Health Insurance
National Health Services
Regional Health Planning
 Combine the terms in the query using Boolean operators.

Methods
13
 Establish limits on the search
Limit the search to the timespan:

1994 to 2012
Limit the search to articles in:
 English

French
Excluded articles on:
 Maths

Veterinary Sciences

History
 Anthropology

Chemistry
 Physics

Architecture
 Geography

Linguistics
 Religion

Zoology
Languages
Timespan
Subject areas

Methods
14
 Insert queries in three different Databases
DATABASES
851 1312
TOTAL: 4362
2199

15
Methods
–
(("Electronic Health Record*" OR "Electronic Medical
Record*" OR "Electronic Patient Record*" OR "Computer*
Patient Record*" OR "Computer* Health record*" OR
"Computer* Medical Record*" OR "Digital Health Record*"
OR "Digital medical record*" OR "Digital patient record*")
AND ("Cost-benefit" OR cost OR costs))

16
Methods
Topic=((("Electronic Health Record*" OR "Electronic Medical
Record*" OR "Electronic Patient Record*" OR "Computer* Patient
Record*" OR "Computer* Health record*" OR "Computer* Medical
Record*" OR "Digital Health Record*" OR "Digital medical record*"
OR "Digital patient record*") AND ("Cost-benefit" OR cost OR costs)))
Refined by: [excluding] Subject Areas=( VETERINARY SCIENCES OR
HISTORY OR ANTHROPOLOGY OR CHEMISTRY OR PHYSICS OR
ARCHITECTURE OR GEOGRAPHY OR LINGUISTICS OR RELIGION OR
ZOOLOGY ) AND Languages=( ENGLISH OR UNSPECIFIED OR FRENCH )
Timespan=1994-2012.

17
Methods
–
(("Electronic Health Record*" OR "Electronic Medical Record*" OR "Electronic
Patient Record*" OR "Computer* Patient Record*" OR"Computer* Health record*"
OR "Computer* Medical Record*" OR "Digital Health Record*" OR "Digital medical record*" OR "Digital patient record*") AND ("Cost-benefit" OR cost OR costs)))
AND (EXCLUDE(SUBJAREA, "CENG") OR EXCLUDE(SUBJAREA, "MATH") OR
EXCLUDE(SUBJAREA, "PHYS") OREXCLUDE(SUBJAREA, "AGRI") OR
EXCLUDE(SUBJAREA, "MATE") OR EXCLUDE(SUBJAREA, "ENVI") OR
EXCLUDE(SUBJAREA, "ARTS") OREXCLUDE(SUBJAREA, "VETE") OR
EXCLUDE(SUBJAREA, "CHEM")) AND (LIMIT-TO(LANGUAGE, "English") OR LIMIT-
TO(LANGUAGE, "French")) AND (LIMIT-TO(PUBYEAR, 2012) OR LIMIT-TO(PUBYEAR,
2011) OR LIMIT-TO(PUBYEAR, 2010) OR LIMIT-TO(PUBYEAR, 2009) OR LIMIT-
TO(PUBYEAR, 2008) OR LIMIT-TO(PUBYEAR, 2007) OR LIMIT-TO(PUBYEAR, 2006)
OR LIMIT-TO(PUBYEAR, 2005) OR LIMIT-TO(PUBYEAR, 2004) OR LIMIT-
TO(PUBYEAR, 2003) OR LIMIT-TO(PUBYEAR, 2002) OR LIMIT-TO(PUBYEAR, 2001) OR
LIMIT-TO(PUBYEAR, 2000) OR LIMIT-TO(PUBYEAR, 1999) OR LIMIT-TO(PUBYEAR,
1998) OR LIMIT-TO(PUBYEAR, 1997) OR LIMIT-TO(PUBYEAR, 1996) OR LIMIT-
TO(PUBYEAR, 1995) OR LIMIT-TO(PUBYEAR, 1994))

Methods
–
18
 Exclude the repeated articles
 Exclude the non-real articles (ex: letters, conversations, news)
 First exclusion by abstract with two revisors
EXCLUSION CRITERIA OF THE FIRST EXCLUSION
 1 st : Not mentioning monetary values/ costs;
 2 nd : Refering to a single hospital/institution;
 3 rd : Refering to a group of services in a certain hospital.
INCLUSION CRITERIA OF THE FIRST EXCLUSION
 1 st : Mentioning Electronic Health Records;
 2 nd : Mentioning Cost-Benefit Analysis;
 3 rd : Referring to monetary values / costs;
 4 th : Dealing only with regional and/or national aspects.

Methods
–
19
 Exclude the articles from previous years than 2008
 Get the full-texts available – search on 7 different databases (PubMed, Google Scholar, B-On, Scopus, Isi
Web of Knowledge, AtoZ, EBSCO)
 Contact the authors to ask for the articles of interest that were not available
 Second exclusion reading the full-article, according to the same parameters as the first one
 Extract data from the articles

20
Methods
Total of documents found
Total of articles without the repeated ones
Total of articles only with the real ones
4362
2937
2621
 Repeated: 1425
 Not articles: 316

21
Methods
Total of articles
Total of articles included by both revisers
306
Total of articles after the year 2008
147
2621

22
Methods
Total of articles after the year 2008
Full-text articles available
Articles after contact with authors
Articles included by both revisors 48
105
111
147

23
Methods

Country where the system is implemented

Date of article publication

Institutions involved

What type of medical data is integrated

User groups

Financing agents

Cost Savings

Costs of initial investment

Profit

Results
24







Results
25









Results
26












Results
27










Results
28





29
Results
Country
USA
USA
USA
USA (Massachussets and
New York)
USA
USA
USA (California)
USA
USA
USA
USA
United Kingdom
USA
USA
USA
USA
USA
USA
Mean
Initial Investment ($)
19 billion
77.8 billion
30 billion
36 500
19 billion
2,55 billion
59.2 billion
195 million
19.2 billion
19 billion
20 billion
32 billion
28 billion
31.4 million
630 000
130 billion
32 billion
17,2 billion
24 billion

30
Results
Country
USA (Minnesota)
Korea
USA
USA
USA
USA
USA
USA
USA
USA
USA
USA
USA (Rhode Island)
Mean
Cost Savings ($/year)
60 million
2,7 billion
81 billion
77 billion
667 896
46 400
1,2 million
81 billion
6 million
20 billion
30 billion
35 million
42 000
22 billion

Conclusions
31

In terms of cost savings, we studied them per year.

The investment from government or other entities was, in mean, 24 billion dollars , being the highest value from the USA, 77.8 billion dollars and the lowest
36500 , also from USA (Massachusetts and New York).

Our data related to cost savings came from 13 articles that referred values varying from 81 billion dollars to
42000 dollars.

In mean, 22 billion dollars were saved per year with EHR.

With two exceptions (Korea and UK), all of this was related to USA medical institutions.

32
Conclusions

From this point of view, EHR appear as advantageous. However, when compared to the mean of investment, which is 24 billion, we observe that this is not that linear.

In terms of profit, the target articles almost didn’t contain this type of information. Just some of them stated that the profit was
11billion, 20-30 billion, 1-2 million or 154,900 per year.

33
Conclusions

One of the main limitations to our project was the lack of relevant information in the final articles selected

The access to the full-text of many articles was denied and when asking the authors to provide us their articles, the majority did not answer us

The variables related to monetary values, such as initial cost investment, cost savings and profit, did not gathered information in every article

34
Conclusion

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